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Amputation Stump Infection. Prof Jai Kulkarni / Dr. Basu ST6 Disablement Services Centre University Hospitals of South Manchester May 2012. Is it an infected stump or not ?. Infection Continuum.

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amputation stump infection

Amputation Stump Infection

Prof Jai Kulkarni / Dr. Basu ST6

Disablement Services Centre

University Hospitals of South Manchester

May 2012

slide4

Wound Contamination: Presence of bacteria within the wound but with no host reaction. Does not delay wound healing.

  • Wound colonisation: Presence of bacteria in the wound which do multiply. No delay to healing and no host reaction.
  • Critical colonisation: Multiplication of bacteria in a wound causing a delay in healing. Increased pain with thick slough and malodour. No cellulitis.
wound infection
Wound Infection

Multiplication of bacteria in the wound with host reaction

Erythema

Pain/heat/swelling

Increase in exudates

Asc lymphangitis and Prox lymphadinopathy +/-

Systemic symptoms

slide6

Lower limb amputations account for the majority of all amputations in the UK, with PVD and diabetes being the major reasons for surgery – 80%

Within the population of patients with dysvascularity, major lower extremity amputation results in significant peri-operative morbidity and mortality.

Potential wound-healing complications associated with lower limb amputation stumps include infection, tissue necrosis, pain, problems with the surrounding skin, scar adhesion, haematoma, stump oedema, osteomyelitis and dehiscence.

The highest rate of surgical site infection is associated with lower limb amputations.

Wound healing outcomes for amputees can be maximised by MDT working.

slide7

Wound healing complications associated with the stump of an amputee are important because in some cases these determine a patient's ability to walk with a prosthetic limb.

Commonest stump-related complications were wound infection and poor healing (70%), poorly fashioned stumps (20%) and phantom pain (10%)

White SA, Thompson MM, Zickerman AM, Broomhead P, Critchley P, Barrie WW, et al. Lower limb amputation and grade of surgeon. Br J Surg 1997; 84(4): 509-11.

The healing rates for below- and above-knee amputations vary considerably. It is thought that a total of 90% of above-knee major amputations heal, 70% primarily, whereas for below-knee amputations, primary healing rates range between 30% and 92%, with a re-fashioning rate of up to 30%.

Dormandy J, Heeck L, Vig S. Major amputations: clinical patterns and predictors. SeminVascSurg 1999; 12(2): 154-61

wound healing

Wound Healing

Inflammation phase with haemostasis (approx 1-7 days):

Initially white blood cells are attracted to wound. Leucocytes get rid of the wound contaminants. Neutrophils assist in destroying bacteria.

At 2-3 days macrophages assist in cleaning wound of bacteria

Slough common at this stage. As cells engulf bacteria they float to surface of wound and die = slough

Proliferation phase (approx 4-24 days): Components are

a) Granulation (new wound matrix provides the scaffolding for new blood vessels). Macrophages- continue to destroy bacteria - release growth factors to attract fibroblasts - stimulate fibroblasts to produce collagen-send for endothelial cells to form new capillary loops. New capillary network formed in wound bed as well as new connective tissue

b) Wound contraction: Myofibroblasts are produced. They congregate at the wound edges and contract allowing the wound edges to come together.

c) Epithelialisation (resurfaces the wound): This is the re surfacing of the wound by new skin cells.

New cells multiply and migrate. Process aided by moist wound environment. Wound bed must be clean and free from devitalised tissue

Maturation phase (20days- 1 year):

Can take up to 1 year. Re modelling of collagen into a more structured tissue occurs. Wound becomes paler and flatter as vascularisation decreases. Tensile strength improves

unhealed stump is not always infected
Unhealed stump is not always infected

“Unhealed” stumps often show healing at the ends of the suture line. Unhealed over the bone.

When is an unhealed stump suitable for prosthetic fitment?

No standard

Various centres use different regimes

Small wounds ok

Leave until fully healed

Early walking aid only

Can we apply force/friction to a dressed wound?

What are the benefits of exercise?

Builds muscle

Helps claudication

Improves general fitness

evidence

Evidence

Early post-op rehabilitation results in improved functional outcomes

(Friedman 1990;Munin 2001).

Compression and EWAs result in quicker progression to prosthetic rehabilitation

(Condie 1998).

Friedmann LW. (1990) Rehabilitation of the lower extremity amputee. In: Kottke FJ, Lehmann JF, editors. Krusen’s handbook of physical medicine and rehabilitation (4th edition) Philadelphia: WB Saunders Company p 1024-69.

Munin MC, Espejo-DeGuzman MC, Boninger ML, Fitzgerald SG, Penrod LE, Singh J (2001) Predictive factors for success in early prosthetic ambulation amongst lower limb amputees. Journal of Rehabilitation Research and Development 38(4): p 379-84.

Condie ME, Treweek SP, Ruclkey CV (1998). Trends in lower limb management: 3 year results from a national survey. British Journal of Surgery 85 (supp1) 23.

Van Ross ERE, Abbott CA, Johnson S (2009) Effects of early mobilisation on unhealed dysvasculartranstibial amputation stumps:A clinical trial Arch Phys Med Rehab 90(4):610-17.

slide14

Advantages of Transtibial Amputations

Improved function

Lower energy requirement for

mobilisation

Easier to don/doff

Reduced chance of prosthetic

abandonment

Improved survival

Lower dependency on family/state

Cheaper to rehabilitate

Benefits of early mobilisation protocol:

Promote TT instead of TF amputation.

Prevent joint contractures/muscle wasting.

Psychological boost for pts.

Rehab and wound healing occur simultaneously.

Optimal functional outcomes.

infection of stump

Infection of Stump

Dermatological infection: 30% of cases

Allergic Contact Dermatitis ( ACD ) frequently appears as a macular, papular, erythematous rash that is often pruritic. The liner, socks, and suspension mechanism are the usual culprits for contact dermatitis. Occurs in 1/3 rd of these cases.

Cysts and sweating can be signs of excessive shear forces and components that are improperly fitted; sweating can also result from the loss of surface area

Tinea infections are caused by excessive moisture – Fungal culture and treatment

Skin maceration

Folliculitis is an infection of the hair follicles caused by poor hygiene, sweating, and poor socket fit; treatment includes use of antiseptic cleaner and topical ointments; socket modification may be required to avoid high-pressure areas

An epidermoid cyst (hydradinitis Suppurativa) is a sebaceous gland that is plugged with keratin; treatment includes the use of topical or oral antibiotics, as well as incision and drainage or excision

is it an infected stump
Is it an infected Stump

Verrucose hyperplasia that has developed after choke syndrome. Choke syndrome develops when

tight proximal socket impairs venous return and

lack of total contact occurs between the residual limb and the prosthetic socket.

Acutely, significant edema leads to weeping and blistering skin. As the choke becomes chronic, the tissues become thickened and indurated. Hemosiderin deposition causes hyperpigmentation of the skin

infection of stump1

Infection of Stump

Soft Tissue and Bony Infection

Bursitis

FB like - Bone wax

Infected thrombosed Vascular graft

Management of infection of major amputation stumps after failed femorodistal grafts. Rubin JR, Yao JS, Thompson RG, Bergan JJ; Surgery 1985; Oct .

Delayed stump healing was noted to occur more commonly in the group who had undergone previous bypasses as opposed to those who had undergone primary amputation (34.8% versus 14.3%). Fourteen graft infections developed in 89 patients after amputation (15.7%), which is significantly higher than the overall 1.4% incidence of lower-extremity bypass infections that occurred during the same interval in patients with intact extremities. In addition, it was found that when infected grafts in amputated limbs were completely removed, stump healing without recurrent wound and graft sepsis was better than when treated locally or with partial graft removal. We therefore recommend removal of a thrombosed graft with an infected wound or an infected graft at the time of major limb amputation to decrease the incidence of wound complications and graft infection.

Bony fragments

Breakage of adhered scar with secondary infection

Bony infection and Osteomyelitis

slide20
There  is  extensive  diffuse  high 

signal  in  the  vastusmedialis,intermedius  and  the  lateralis  and 

distal  rectus  femoris  muscles.

(also adductor  magnus )Suspicious  of  muscle  infection(pyomyositis).

Poor  outline  of    cortical  margins 

of  the  femur in  the  distally (approximately  6  cm),  some  enhancement  is  seen  alongespecially  within  the  marrow  on 

post  gadolinium  images

A  few  low  signal  foci  probably 

representing  bony  fragments 

There  is  probably  a  small  collection  at  the  end  of  the  stump  shown  A  small  sinus  tract  is  seen  at  the 

anterolateral  aspect  of  the  stump

after re fashioning of stump
After Re-fashioning of stump

Immediately after surgery

Recent Picture – healing by 2* intension

good surgical technique and oedema management prevents stump infection
Good Surgical technique and Oedema management prevents stump infection

De-bulk flap to give ideal stump shape which allows earlier casting

Anterior beveling of tibia

Allow for oedema in closure to prevent tension on suture line

Interrupted skin closure to allow drainage

Sutures not clips to allow for early compression

Post operative management with early Compression stockinet (Not with skin clip) or Rigid Removable Dressing (RRD)

Volume control

Better wound healing

Protection of stump (fall)

Lowers the risk of knee contracture

Reduces hospital stay and Prosthesis fitting time

management

Management

Treat Stump infection early and prompt

As it may lead to stump dehiscence and higher amputation

It can cause serious systemic infection

Delays the Prosthetic rehabilitation

Prosthetic modification is immensely important for the holistic management.